Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.
Medical Records Systems, Computerized
Electronic Health Records
Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.
The intentional infliction of physical or mental suffering upon an individual or individuals, including the torture of animals.
Forms and Records Control
Ambulatory Care Information Systems
Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.
Human Rights Abuses
Deliberate maltreatment of groups of humans beings including violations of generally-accepted fundamental rights as stated by the Universal Declaration of Human Rights, adopted and proclaimed by the United Nations General Assembly resolution 217 A (III) of 10 December 1948.
Time and Motion Studies
Hospital Information Systems
Quality Assurance, Health Care
Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.
Medical History Taking
A loose confederation of computer communication networks around the world. The networks that make up the Internet are connected through several backbone networks. The Internet grew out of the US Government ARPAnet project and was designed to facilitate information exchange.
Information Storage and Retrieval
Evaluation of the nature and extent of nursing problems presented by a patient for the purpose of patient care planning.
Medical Records, Problem-Oriented
Nursing Evaluation Research
Research carried out by nurses that uses interviews, data collection, observation, surveys, etc., to evaluate nursing, health, clinical, and nursing education programs and curricula, and which also demonstrates the value of such evaluation.
Anterior Cruciate Ligament
A type of MICROCOMPUTER, sometimes called a personal digital assistant, that is very small and portable and fitting in a hand. They are convenient to use in clinical and other field situations for quick data management. They usually require docking with MICROCOMPUTERS for updates.
Patient Care Planning
Usually a written medical and nursing care program designed for a particular patient.
Practice Guidelines as Topic
Directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery.
Physician's Practice Patterns
Quality of Health Care
A sultanate on the southeast coast of the Arabian peninsula. Its capital is Masqat. Before the 16th century it was ruled by independent emirs but was captured and controlled by the Portuguese 1508-1648. In 1741 it was recovered by a descendent of Yemen's imam. After its decline in the 19th century, it became virtually a political and economic dependency within the British Government of India, retaining close ties with Great Britain by treaty from 1939 to 1970 when it achieved autonomy. The name was recorded by Pliny in the 1st century A.D. as Omana, said to be derived from the founder of the state, Oman ben Ibrahim al-Khalil. (From Webster's New Geographical Dictionary, 1988, p890; Oman Embassy, Washington; Room, Brewer's Dictionary of Names, 1992, p391)
Extensive collections, reputedly complete, of facts and data garnered from material of a specialized subject area and made available for analysis and application. The collection can be automated by various contemporary methods for retrieval. The concept should be differentiated from DATABASES, BIBLIOGRAPHIC which is restricted to collections of bibliographic references.
Insurance, Health, Reimbursement
Anterior Cruciate Ligament Reconstruction
Rebuilding of the ANTERIOR CRUCIATE LIGAMENT to restore functional stability of the knee. AUTOGRAFTING or ALLOGRAFTING of tissues is often used.
The process of pictorial communication, between human and computers, in which the computer input and output have the form of charts, drawings, or other appropriate pictorial representation.
Database Management Systems
Quality Indicators, Health Care
Norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.
Diagnostic Techniques, Digestive System
Primary Health Care
Emergency Service, Hospital
A specified list of terms with a fixed and unalterable meaning, and from which a selection is made when CATALOGING; ABSTRACTING AND INDEXING; or searching BOOKS; JOURNALS AS TOPIC; and other documents. The control is intended to avoid the scattering of related subjects under different headings (SUBJECT HEADINGS). The list may be altered or extended only by the publisher or issuing agency. (From Harrod's Librarians' Glossary, 7th ed, p163)
Advance Care Planning
Internship and Residency
A nursing specialty involving nursing care given to the pregnant patient before, after, or during childbirth.
Documents describing a medical treatment or research project, including proposed procedures, risks, and alternatives, that are to be signed by an individual, or the individual's proxy, to indicate his/her understanding of the document and a willingness to undergo the treatment or to participate in the research.
Medical Staff, Hospital
Total Quality Management
Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.
Advance Directive Adherence
Compliance by health personnel or proxies with the stipulations of ADVANCE DIRECTIVES (or similar directives such as RESUSCITATION ORDERS) when patients are unable to direct their own care.
Records as Topic
The commitment in writing, as authentic evidence, of something having legal importance. The concept includes certificates of birth, death, etc., as well as hospital, medical, and other institutional records.
Terminology as Topic
A field of biology concerned with the development of techniques for the collection and manipulation of biological data, and the use of such data to make biological discoveries or predictions. This field encompasses all computational methods and theories for solving biological problems including manipulation of models and datasets.
Operating Room Information Systems
Attitude of Health Personnel
The transferring of patient care responsibility from one health-care professional to another.
Specifications and instructions applied to the software.
The capability to perform acceptably those duties directly related to patient care.
Process Assessment (Health Care)
An evaluation procedure that focuses on how care is delivered, based on the premise that there are standards of performance for activities undertaken in delivering patient care, in which the specific actions taken, events occurring, and human interactions are compared with accepted standards.
Natural Language Processing
Pharmacy Service, Hospital
Ambulatory Care Facilities
Wounds and Injuries
Text editing and storage functions using computer software.
International Classification of Diseases
A system of categories to which morbid entries are assigned according to established criteria. Included is the entire range of conditions in a manageable number of categories, grouped to facilitate mortality reporting. It is produced by the World Health Organization (From ICD-10, p1). The Clinical Modifications, produced by the UNITED STATES DEPT. OF HEALTH AND HUMAN SERVICES, are larger extensions used for morbidity and general epidemiological purposes, primarily in the U.S.
Referral by physicians to testing or treatment facilities in which they have financial interest. The practice is regulated by the Ethics in Patient Referrals Act of 1989.
Maintenance of the hygienic state of the skin under optimal conditions of cleanliness and comfort. Effective in skin care are proper washing, bathing, cleansing, and the use of soaps, detergents, oils, etc. In various disease states, therapeutic and protective solutions and ointments are useful. The care of the skin is particularly important in various occupations, in exposure to sunlight, in neonates, and in PRESSURE ULCER.
Decision Support Systems, Clinical
Computer-based information systems used to integrate clinical and patient information and provide support for decision-making in patient care.
Guidelines as Topic
A systematic statement of policy rules or principles. Guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by convening expert panels. The text may be cursive or in outline form but is generally a comprehensive guide to problems and approaches in any field of activity. For guidelines in the field of health care and clinical medicine, PRACTICE GUIDELINES AS TOPIC is available.
The act, process, or an instance of narrating, i.e., telling a story. In the context of MEDICINE or ETHICS, narration includes relating the particular and the personal in the life story of an individual.
United States Department of Defense
A cabinet department in the Executive Branch of the United States Government whose mission is to provide the military forces needed to deter WARFARE and to protect the security of our country.
Theoretical models simulating behavior or activities in nursing, including nursing care, management and economics, theory, assessment, research, and education. Some examples of these models include Orem Self-Care Model, Roy Adaptation Model, and Rogers Life Process Model.
Centers for Medicare and Medicaid Services (U.S.)
A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.
Academic Medical Centers
Practice Management, Medical
Medical Informatics Applications
Automated systems applied to the patient care process including diagnosis, therapy, and systems of communicating medical data within the health care setting.
An organized procedure carried out by a select committee of professionals in evaluating the performance of other professionals in meeting the standards of their specialty. Review by peers is used by editors in the evaluation of articles and other papers submitted for publication. Peer review is used also in the evaluation of grant applications. It is applied also in evaluating the quality of health care provided to patients.
Radiology Department, Hospital
Pathology Department, Hospital
A detailed review and evaluation of selected clinical records by qualified professional personnel to improve the quality of patient care and outcomes. The clinical audit was formally introduced in 1993 into the United Kingdom's National Health Service.
Using certified ELECTRONIC HEALTH RECORDS technology to improve quality, safety, efficiency, and reduce HEALTHCARE DISPARITIES; engage patients and families in their health care; improve care coordination; improve population and public health; while maintaining privacy and security.
Abstracting and Indexing as Topic
Reproducibility of Results
The statistical reproducibility of measurements (often in a clinical context), including the testing of instrumentation or techniques to obtain reproducible results. The concept includes reproducibility of physiological measurements, which may be used to develop rules to assess probability or prognosis, or response to a stimulus; reproducibility of occurrence of a condition; and reproducibility of experimental results.
Bone-Patellar Tendon-Bone Grafting
Fixation of the ANTERIOR CRUCIATE LIGAMENT, during surgical reconstruction, by the use of a bone-patellar tendon graft.
Total pharmaceutical services provided by qualified PHARMACISTS. In addition to the preparation and distribution of medical products, they may include consultative services provided to agencies and institutions which do not have a qualified pharmacist.
Medical Records Department, Hospital
Hospital department responsible for the creating, care, storage and retrieval of medical records. It also provides statistical information for the medical and administrative staff.
Medication Systems, Hospital
Overall systems, traditional or automated, to provide medication to patients in hospitals. Elements of the system are: handling the physician's order, transcription of the order by nurse and/or pharmacist, filling the medication order, transfer to the nursing unit, and administration to the patient.
Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.
A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care.
Compliance with a set of standards defined by non-governmental organizations. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved, e.g., certification for a medical specialty.
Outpatient Clinics, Hospital
Continuity of Patient Care
Speech Recognition Software
Reconstructive Surgical Procedures
Medical Order Entry Systems
Information systems, usually computer-assisted, that enable providers to initiate medical procedures, prescribe medications, etc. These systems support medical decision-making and error-reduction during patient care.
Small computers using LSI (large-scale integration) microprocessor chips as the CPU (central processing unit) and semiconductor memories for compact, inexpensive storage of program instructions and data. They are smaller and less expensive than minicomputers and are usually built into a dedicated system where they are optimized for a particular application. "Microprocessor" may refer to just the CPU or the entire microcomputer.
A form of therapy that employs a coordinated and interdisciplinary approach for easing the suffering and improving the quality of life of those experiencing pain.
Materials or substances used in the composition of traditional medical remedies. The use of this term in MeSH was formerly restricted to historical articles or those concerned with traditional medicine, but it can also refer to homeopathic remedies. Nosodes are specific types of homeopathic remedies prepared from causal agents or disease products.
A province of Canada lying between the provinces of Manitoba and Quebec. Its capital is Toronto. It takes its name from Lake Ontario which is said to represent the Iroquois oniatariio, beautiful lake. (From Webster's New Geographical Dictionary, 1988, p892 & Room, Brewer's Dictionary of Names, 1992, p391)
The process of formulating, improving, and expanding educational, managerial, or service-oriented work plans (excluding computer program development).
United States Department of Veterans Affairs
A cabinet department in the Executive Branch of the United States Government concerned with overall planning, promoting, and administering programs pertaining to VETERANS. It was established March 15, 1989 as a Cabinet-level position.
Joint Commission on Accreditation of Healthcare Organizations
Emergency Medical Technicians
Paramedical personnel trained to provide basic emergency care and life support under the supervision of physicians and/or nurses. These services may be carried out at the site of the emergency, in the ambulance, or in a health care institution.